Ruminations by a non-academic general surgeon from the heart of the rust belt.

Thursday, December 18, 2008

Staying Overnight for the First Time

I have a guy in house now who underwent a repair of a giant paraesophageal hernia last week. He's in his 70's, retired and tough as a box of nails. He served in Korea and then came home and was a foreman on a factory line for 30 years. For the past several years he'd been suffering from this giant hiatal hernia where half his stomach was lodged in his chest, crushing his left lung. For years his GI guy and his wife had been insisting that he consider surgery. Hell no, he'd always replied. Finally he relented. He couldn't sleep at night, couldn't catch his breath while recumbent.

The surgery was tough. Usually I can get the stomach and the hernia sac down into the abdomen laparoscopically but his was chronically incarcerated. It didn't want to slide down the way they sometimes can. I didn't want to tear the stomach so I had to convert to an open procedure. The post operative course was complicated by a pulmonary embolus (despite compression boots and prophylactic Lovenox, never event indeed!) and so his hospitalization has been longer than any of us anticipated. Initially, after the PE was diagnosed, he was on a non-rebreather mask and you couldn't really converse with him all that well. Is was like someone trying to talk to you underwater.

One day, he grabbed my hand while I was making rounds. He has these thick, hulking, calloused hands, the knuckles gnarled and jutting off in odd directions and I'm always nervous if I'll ever see my palm again whenever he wants to shake it. I have to tell you something, he said, his voice muffled and distant behind the mask. I helped him lift it away from his mouth. I watched his oxygen saturations closely. -I'm going to be Ok, right? he said.-Yeah. You're a tough old bastard. You're going to be fine.He nodded. He took a deep breath. He was gasping a bit. -You know in 51 years of marriage we've never spent this many nights...He stopped. His eyes were swollen and red rimmed. He was fighting to catch his breath, but also, he just didn't want to go on, having said too much already to this young doctor.-It's ok buddy, I said. I know what you're saying. I slugged him in the shoulder, or some such awkward attempt at male affection and helped him with the oxygen mask. -You'll see her soon, I said. You be sleeping next to her again before you know it. I promise you....

7 comments:

I just wanted to let you know I found your blog a month ago or so and have just finished reading it from the start. You're a good writer and I appreciate the high ratio of "cases" you discuss compared to political pieces (which are also interesting when posted). Most med blogs I follow have seemed to progressively move away from medicine to medical policy, which is not surprising given the current state of things. I'm a post-bacc student (interested in surgery), hoping to apply in a little over a year, and it's great to read stories from someone that obviously chose the profession out of passion. Anyway, just wanted to say thank you for providing this insightful and entertaining blog, keep it up. I hope your "paraesophageal" (I've learned a ridiculous amount of anatomy and other terms reading your blog haha) patient continues to improve.

I want to echo what ERob said. I love reading your stories about actual surgical care in these blogs. He's right about others turning into political blogs (e.g. Surgeonsblog) which are simply not as fun to read for me.

You said you had trouble getting the hernia sac down because it was chronically incarcerated. Would the procedure have been easier had the patient sought treatment when the hernia first occurred? Did the long wait lead to connective tissues or other growth binding the hernia into place?

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